A Destructive Blast From The Past

A cheery letter on 12/1/14 by UnitedHealthcare’s Optum business unit noted that the company was ‘pleased to announce’ that its new Charter product group would impose a ‘new’ requirement on its members. In this new product, members will be required to choose a primary care physician and seek their approval for a referral to a doctor of chiropractic.

Not only did it seem like a cold blast from the unfortunate past, but it also seemed to signify that the profession has turned a corner in its relationship with the health care system–and turning that corner has led us into a blind alley with no way out. As a profession we should be very, very concerned about the implications of this action. And only look as far as the bathroom mirror for whom to blame.

Let’s imagine that an argument can be made that this business strategy (because that’s all it is, an effort to limit exposure to a source of expense) will result in the potential of more people seeking chiropractic care by making it seem ‘safe and accepted.’ As dubious as the concept may be, some may argue that some people who would not normally feel comfortable seeking chiropractic care would feel a bit more so with a physician’s referral in hand. Perhaps. Unfortunately, it’s much more likely to function as a barrier to care, with some real consequences–intended and otherwise.

But what stands out more to me is how this signifies what we have lost. Let’s review some of those implications–understanding that this is (for now, at least) unique to UnitedHealthcare:

  • In this model, we’ve lost the ability to function as portal of entry providers, thereby weakening any attempt as a profession to improve the performance and accountability of doctors of chiropractic to function responsibly in that role. We’ve abdicated the responsibility for our own cultural maturation and development, and it’s now in the hands of political medicine. As they say, good luck with that.
  • By accepting a gatekeeper’s approval we’ve lost the ability to define any deeper understanding of any broader context for care. As a licensed profession we need to have the freedom to develop a fuller understanding of the need for and the effects of chiropractic care. But with medical doctors defining the context for care as a basis for referral that’s acceptable within their own clinical paradigm, we should have no illusions about what will be approved. Or that it will result in more and more narrow parameters for approved care.
  • And the bigger picture shows that in this approach we’ve lost the ability as a profession to establish a distinct model of health and wellness that corresponds to our clinical paradigm of optimal neurologic function. We have accepted the parameters of data gathering, management and interpretation as defined by political medicine and the business metrics of UnitedHealthcare. Our acceptance of this mode of subjugation means that we’ve lost control of defining our own profession on our terms.
  • In addition, this action will support those who want to add medical responsibilities to chiropractic scopes of practice law, further fracturing and tiering the profession into two distinct groups. If this concept spreads, chiropractic schools will be in even more trouble than they are already. How will they sell an education that costs over $100K to prepare someone to function as a physician’s chiropractic assistant?

Taken together, the practical impact of this ‘product’ is that we’re back to an even worse position than we were with medical gatekeepers in the late 1980s. It didn’t work then, and the fate of these ‘new’ products is yet to be seen, but because of the intense cost management pressures in health care no one should bet against the concept spreading.

Consumers are less bound by benefits restrictions than they were in the 1980s. There are more choices now and more options for making them in the health care marketplace. So it will be interesting to see what consumers do with this. It’s at least likely to drive them further ‘underground’ in what they feel comfortable telling their medical doctors about. And with the shrinking economic value of a chiropractic ‘benefit’ in most insurance plans, it’s also likely to drive those expenses off the books for insurance companies and fully to the checkbooks of plan members. That likelihood could not have escaped the planning efforts of those behind this type of misguided product. So everybody wins–except for chiropractors and their patients.

We have no power to make an argument against this practice because we have accepted the terms of engagement with insurance companies. At a time when the phrase ‘evidence-based’ is everywhere, the reality of the limitations of that approach are rarely discussed. Dr. Larry Dossey’s recent article about this in the Huffington Post is a sober review of what some understand but many miss: that most of what passes for normal medical care simply has no evidence to support its effectiveness. Worse, billions of dollars are spent on things that are simply ineffective or even harmful. And because political medicine’s fox is in charge of the insurance company hen-house there’s no one in a position of cultural authority to point out the problems this creates.

A pessimistic read on all this is that, for a profession with weak evidence based on the wrong questions we’ve now accepted a subordinate role to a profession whose own practices for the same kinds of problems and conditions have even less support. What could possibly be wrong with that?

Because as a profession we spend more time avoiding collaboration, cleaning up our own act and working to strengthen our position, we’re allowing ourselves to be neatly boxed up and controlled. Political medicine has only had to be patient and watch as our internecine warfare weakened us to the point where we, faced with this new affront dredged up from the past, can only meekly accept it.

The Emperor has no clothes, and yet we’ve accepted the role of his valet.


This entry was posted in Chiropractic, Futures discussion, Political Medicine, Professional Relationships. Bookmark the permalink.

7 Responses to A Destructive Blast From The Past

  1. Lisa says:

    aren’t we sick of insurance yet? the entire profession needs to go cash.

  2. Bill Barrett DC says:

    Dr. Bolles,
    Thank you for your thoughtful insights.
    I worked alongside Dr. Hynan attempting to change the health plan and medical community attitudes and perspective regarding our chiropractic profession. He is correct. The blame is not all ours.
    What I learned is at the end of the day the CONSUMER, our patients, want the BEST health care that SOMEONE ELSE pays for. I am certain the new UHG product is less costly than products that do not require a gatekeeper.
    Only when they cannot get the referral for chiropractic care will the patient realize that in health care, as in life, you get what you pay for.

    • Stephen Bolles says:

      Dr. Barrett’s contributions to the profession are notable, and he is right: the blame is not all ours. I am not suggesting that it is. What I am trying to point out is that there have been benefits and problems associated with our choices about being part of the insurance system paradigm that are separate from single issues like compensation, and because there are implications we did not foresee, it’s time to give serious thought–and action–to the consequences of all this. Fundamentally, if we don’t seek an explicit role in defining our own paradigm–and accept the responsibilities of this–the strictures we operate under will only increase.

  3. Gregory J. Hynan says:

    Dr. Bolles:

    I struggle with the remark “We need look no farther than the bathroom mirror.”

    Perhaps to the contrary the chiropractic profession has arrived. And, with that arrival there is a stronger movement to control the application/delivery of a procedure that has stood the test of time, stood the public’s scrutiny, and stood the onslaught of organized medicine’s attempt to destroy a vital health care procedure. I dare say any one of those is a challenge few professions or business entities could survive, let alone trying to survive against all three.

    For the first eighty (80) or ninety (90) years of the chiropractic professions existence it was an interesting time to practice chiropractic. One never new what derogatory response would come from some individual at a social gathering, from a new or existing patient, from a neighbor, or from the media relative to a practice of chiropractic they had been exposed to or heard of. Tough times and tougher yet to try and explain away those remarks in the few short minutes available for debate or discussion.

    Today I am proud to say that a new patient will walk into my clinic or I will meet an individual at a social gathering and I will only hear complimentary conversations surrounding the experience the new patient or that individual had with their doctor of chiropractic. It is the exceedingly rare occasion I find myself on the defense.

    I am proud to say that I believe our profession is doing an outstanding job; I repeat an outstanding job. I believe it speaks to the quality of the work performed and to the significant health benefits that are gained by those who seek our care.

    I DO NOT believe the benefits of our care is a secret. I DO believe that the “organized’ health care community wants to deliver and control those benefits. Lets not kid ourselves. Data has been collected on us for the past thirty (30) years. The chiropractic profession is either getting it “done” or the “organized” health care community would have shut us down for good.

    In the early 1900’s they told us that what we did was worthless and that they would prove it, in the 1950’s they let us do what we were trained to do but we were told that what we did really didn’t matter relative to affecting one’s health, and I promise you we are about to be told that what we do they have known about all the time.

    When we apply our procedure it is deemed a therapy. When we apply our procedure it is reimbursed far below it’s work effort and it’s value. What we do will be renamed and than claimed for their own. It will than be identified as a procedure and the reimbursement for the “procedure” will be handsome.

    Why do we need to look in the bathroom mirror? Medicine and the insurance industry control health care. One would think their mirror must be very fogged but to the contrary I believe it is crystal clear.

    I like my reflection. I am proud of what I have contributed to my community and I am proud of what my profession has contributed; especially considering the difficult health care environment that is imposed on us.

    We struggle on but it is a worthy struggle.

    Gregory J. Hynan D.C. DABCO

    • Stephen Bolles says:

      If more in our profession had Dr. Hynan’s passion and his family’s accomplishments we’d be in a very different position. My remark about our own agency in our problems has to do with the seduction of insurance coverage, which has always seemed to be a good idea, but in too many instances has led to the profession being held to terms that misrepresent its value and contributions. We have not always understood what we were trading away, and it has hurt us in some very real ways. But Dr. Hynan is right: it is a worthy struggle. It’s just not over yet.

  4. Dr. Frederic Falentin says:

    Maybe we should all get out of any type of third party payor system and start from scratch as a profession. Next we would come together, unite as chiropractors and clearly define what our professional paradigms are without outside limitations and restrictions. Our schools would then all teach within these paradigms and the message would be the same across all practicing chiropractors. We then would proceed to practice according to these principles establishing our own model of health care. And if the health insurance industry in the future would become interested in providing some sort of coverage we would negotiate only on our terms and based on our paradigms, not any established medical model. It would be up to the third party payor system to see and recognize the benefits of our system versus the medical one. The insurance industry woulf finally realize the benefits and cost savings of chiropractic care and run with it!

  5. Dr Dennis French says:

    This is exactly what we were fighting against back in the late ’80s and early ’90s, when a new paradigm was being sold to the Chiropractic profession. “Get our foot in the door, and we will open it to all Chiropractors to be providers.” I feel we that were not allowed to be providers were sold a bag of ____! And now to get a referral from an MD to receive Chiropractic care is like going to a Ford dealer to get permission to buy a Chevy!

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